The physician must complete this standard form, when the injured worker has been placed
under work restrictions, requires accommodations or is temporarily totally disabled.
The MEDCO-14 should be used during evaluation and management services when an
injured worker’s status is evaluated or re-evaluated by a physician,
usually every 30 days.

The MEDCO-14 is similar to forms managed care organizations (MCOs) or physician offices use and provide a permanent record
for the physician’s file. The two-part form allows injured workers to receive a copy for
their records. Fax a copy to the appropriate MCO, so employers will know their injured
workers’ restrictions and explore work site adaptations/modifications.

Easy check-off boxes regarding the work/non-work limitations, physician
instructions, whether the injured worker is temporarily totally disabled,
a request for vocational rehabilitation services, and the date and time of
his or her next appointment.

This form reduces the need for phone calls among the parties to the claim regarding the
injured worker’s return-to-work progress, and provides important information to injured
workers regarding their recovery and work limitations. Injured workers have immediate
information that they can share with their supervisors when they return to the job.
In addition, employers will see the progress of their injured workers from the beginning
of treatment until they are back on the job, and they will be able to assist in successful
return-to-work practices.